t(14;18) Negative Follicular Lymphoma with 1p36 abnormality

associated with In Situ Follicular Neoplasia with t(14;18) translocation

Hematopathology Service

Memorial Sloan Kettering Cancer Center, New York

Pallavi Khattar MD, Jennifer Maerki MD, Alexander Chan MD, Janine Pichardo, Robert

Cimera, Caleb Ho MD, Yanming Zhang MD PhD, Lu Wang MD PhD, Ahmet Dogan MD PhD

SH2017-0334

Clinical History

May 2013

35 y/o female presented with a painless mass in her right

groin.

No c/o fever, night sweats or unexplained weight loss

Laboratory Findings :

CBC (WBC: 6.6 K/ul; HgB: 13.3 g/dl; Hct: 37.3%;

MCV:93 fl; Platelet: 359 K/ul)

LDH: 188 U/L

CT and PET Scan Images: May 2013

Localized mass: Right Groin: 3.5 x 2.4 cm; SUV: 4

Lymph node excision and bone marrow biopsy were performed

Diagnosis : At outside institute

Lymph node: Marginal zone lymphoma

Bone marrow: No morphologic or immunophenotypic evidence

of Lymphoma

Clinical Stage 1A

We received slides for consultation at MSKCC

Clinical History

H&E 20x

H&E: Area with Follicular Lymphoma, In Situ Follicular Neoplasia and Reactive Follicles

In Situ Follicular Neoplasia

Reactive follicles

Follicular Lymphoma

CD20

CD10

Reactive follicles

ISFN

FL- Diffuse areas

Morphologic and immunohistochemical features of Follicular Lymphoma and In Situ Follicular Neoplasia

H&E section shows FL with diffuse areas on right, ISFN (center) and reactive follicles on left (20x)

BCL2

CD23

H&E 20x

H&E 400x

Follicular Lymphoma: Diffuse Growth Pattern

CD20 H&E

CD10

BCL2

CD23BCL6

Ki67

FISH studies using BCL2 Break apart probe: Negative for BCL2 gene rearrangement

Morphologic and immunohistochemical features of Follicular Lymphoma (FL)

Ki67

CD20

CD10BCL2

CD23

BCL6

FISH studies using BCL2 Breakapart probe: Positive for BCL2 gene rearrangement

Morphologic and immunohistochemical features of In Situ Follicular Neoplasia (ISFN)

H&E H&E

Click to edit Master title style

TNFRSF14 Gene

Genetic Studies

1. Copy Neutral – Loss of Heterozygosity (CN-LOH) in 1p35.1p36.33 that harbors TNFRSF14 gene

2. Coexistence of Copy Neutral – Loss of Heterozygosity (CN-LOH) in 16p involving CREBBP gene

Chromosome 1

SNP (Single Nucleotide Polymorphism) array analysis

Chromosome 16

CREBBP Gene

Two mutations were detected in this patient:

1. TNFRSF14 p.Q158* (A change in nucleotide resulting in a premature stop codon), variant

frequency 27.9%

2. CREBBP p.S1436R (Missense mutation), variant frequency 29.5%

Comprehensive Genomic Analysis:

Patient’s normal control (blood) is also sequenced to filter germline variant.

Follicular Lymphoma Diffuse Growth Pattern

In situ Follicular Neoplasia (ISFN)

Immunostains

CD20 Positive Positive

BCL2 Weak to negative Strong

CD10 Dim Strong

BCL6 Variable Variable

CD23 Strong Negative

Cytogenetic Studies

BCL2 gene rearrangement Not detectedDetected (57% of the

cells)

SNP array analysisDetected (CN- LOH in

chromosome 1p35.1p36.33 and 16p)

??

Comprehensive Genomic Analysis

TNFRSF14 p.Q158* ??

CREBBP p.S1436R ??

Summary of Findings

Diagnosis

t(14;18) Negative Follicular Lymphoma with 1p36 abnormality

associated with In Situ Follicular Neoplasia with t(14;18) Translocation

Follow Up

Patient was treated with 24 Gy of involved field radiation therapy

(IFRT), completed in August 2013.

CT scan after treatment- August 2013

Follow up examination showed no clinical or radiological evidence of disease- Complete remission after 45months

In Situ Follicular Neoplasia (ISFN)

(1) How should in situ follicular neoplasia be defined and diagnosed?

(2) Is in situ neoplasia an early step of lymphomagenesis?

(3) How should patients with in situ neoplasia be managed

“in situ” follicular neoplasia without overt lymphoma:

No evidence for starting therapy: “wait-and-watch policy” is strongly suggested.

For patients with concomitant overt lymphoma:

Staging and treatment: based on malignant counterpart.

Emerging issues after the recognition of In Situ Follicular Neoplasia (ISFN) . Leuk Lymphoma. 2014. Carbone A, Gloghini A How I treat: diagnosing and managing “in situ” lymphoma. Blood, 2011. Carbone A and Santoro A

t(14;18) Negative Follicular lymphoma with Diffuse Growth Pattern

Presents as large, localized tumors in inguinal region

Diffuse growth pattern

CD20, BCL2 (dim to negative), CD10 (dim) , BCL6 with CD23

co-expression

Lacks BCL2 gene rearrangement

Deletion in the terminal parts of the short arm of chromosome

1 (1p36).

Low clinical stage, indolent disease

A distinctive subtype of t(14;18)-negative nodal follicular non-Hodgkin lymphoma characterized by a predominantly diffuse growth pattern and deletions in the chromosomal region 1p36. Tiemo Katzenberger, German Ott. Blood 2009

MSKCC t(14;18) Negative Inguinal/ Groin Follicular Lymphoma

Inguinal/ groin FL cases were retrieved from archives of Department of

Hematopathology at MSKCC

Morphologic and immunohistochemical stains were reviewed.

FFPE inguinal/ groin follicular lymphoma tissue samples were analyzed by

BCL2-rearrangement FISH assay (Abbott molecular).

Genomic DNAs extracted from FFPE tumor material were used for copy

number and allelic imbalance analysis by SNP-array (OncoScan,

Affymetrix).

MSKCC t(14;18) Negative Inguinal/ Groin Follicular Lymphoma Cases

Case No.FISH studies: BCL2 gene

rearrangement SNP array analysis: Chromosome 1p SNP array analysis: Chromosome 16p1 Negative CN-LOH of 1p CN-LOH of 16p12.1-ter2 Negative CN-LOH of 1p36.23-ter -3 Negative CN-LOH of 1p36.31-ter CN-LOH of 16p13.13-ter4 Negative CN-LOH of 1p35.2-ter -5 Negative CN-LOH of 1p36.11-ter CN-LOH of 16p11.3-ter6 Negative CN-LOH of 1p36.11-ter -7 Negative del of 1p36.33-36.32 (2.7 Mb) CN-LOH of 16p11.2-ter8 Negative CN-LOH of 1p35.2-ter CN-LOH of 16p11.2-ter9 Negative CN-LOH of 1p36 CN-LOH of 16p13.3-p13.11

10 Negative CN-LOH 1p36.32-ter (2.7 Mb) -11 Negative deletion of 1p36.23-ter -12 Negative deletion of 1p36.23-ter CN-LOH of 16p11.2-ter 13 Negative - CN-LOH of 16p13.13-ter 14 Negative CN-LOH of 1p34.2-ter CN-LOH of 16p11.2-ter 15 Negative CN-LOH 1p36.32-ter (2.9 Mb) -16 Negative CN-LOH 1p33-ter -

17 Negative

deletion of 1p35.1-terFocal homozygous deletion of

TNFRSF14 -18 Negative - CN-LOH of 16p13.13-ter

Cell Biology of TNFRSF14/HVEM: 1p36 Follicular Lymphoma

Diagram representing the concept of CAR-T cells that

produce solHVEM locally and continuously at the

lymphoma site in vivo.

Loss of the HVEM Tumor Suppressor in Lymphoma and Restoration by Modified CAR-T Cells.M. Boice. Cell 2016

Take home message: Inguinal/Groin Follicular Lymphoma with 1p36 abnormality

1. Clinical features

Isolated large inguinal/groin mass

2. Phenotype

CD20, BCL2 (dim to negative), CD10 (dim), BCL6 with CD23 coexpression

3. Molecular work up

FISH Studies: BCL2 gene rearrangement

SNP Array: Deletion or CN-LOH in chromosome 1p36

SNP array, not FISH would be the test of choice for this aberration.

Comprehensive Genomic Analysis: TNFRSF14 gene mutation

Final Panel Diagnosis

t(14;18) Negative Follicular Lymphoma with 1p36 deletion

Thank You